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Minnesota Lawful Gambling <br />LG220 Application for Exempt Permit Fee $50 <br />anizationlnformation <br />9 �� <br />r a�����el <br />���� <br />Page 1 of 2 12/03 <br />er oarra so n k <br />Fee Paid : � I <br />����. <br />Previous lawful gambling exemption number <br />Street i,ity <br />� . ������ r� � �� <br />Name of chief executive offiCer (CEO) <br />�rsl na e Last name <br />� ��r� � � � ���r-M <br />�larrr� af kr�e� rar <br />��L r�ame <br />r�' <br />Type of Nonprofit Organization <br />L�5k f7B <br />L� �i �� <br />Check the box that best describes your organization: <br />❑ Fraternal Religious <br />❑ Veteran ,�• Other nonprofit organization <br />StatelZip Code <br />�� } ���� <br />� <br />County <br />���r � � <br />on� numb�r of �L� <br />Daytime phone number of <br />1teSSu;i� ��� �� - <br />CheCk th box that indicates the type of proof your organization attached'to this application: <br />IRS letter indicating income tax exempt status <br />Certificate of Good Standing from the Minnesota Secretary of State's Office <br />A charter showing you are all affiliate of a parent nonprofit organization <br />Proof previouslv submitted and on file with the Gamblinq Control Boarc <br />amblina Premises Information <br />me or premiseswno�gambung aci <br />�,��� �•��-_��� <br />Address (do not use PO box) <br />� ti � � �� �� Z �� <br />con <br />������ � �� <br />Date(s) of activity(forraffles, indicate the date ofthe drawing <br />�; t�� �� ���� � u�" , � �'� a <br />the drawingwill take place) <br />State/ZipCode I County <br />�i ��I1� <br />Checkthe box orboxes thatindicate the type of gambling activityyourorganization will be conducting: <br />� *Bingo � Raffles (cash prizes may not exceed $12,000) � *Paddlewheels � *Pull-Tabs � "Tipboards <br />*Gambling equipment for pull-tabs, tipboards, paddlewheels, and bingo (bingo paper, hard cards, and bingo ball <br />selection device) must be obtained from a distributor licensed by the Gambling Control Board. To find a licensed <br />distributor, go to www.gcb.state.mn.us and click on Li st of Licensed Distributors. Or call 651-639-4000. <br />This f� will be made available in altemative <br />format(i.e. larqe print: Braille) upon request. <br />The information requested on this form (and <br />any attachments)will be used bythe Gambling <br />Control Board (Board) to determine your <br />qualificationsto be involved i n lawful gambling <br />activitiesinMinnesota. Youhavetherightto <br />refuse to supply the information requested; <br />however, if you refuse to supply this <br />information, the Board may not be able to <br />determine your qualifications and, as a <br />consequence, may refuse to issue you a <br />permit. If you supply the information <br />requested, the Boardwill be ableto process <br />your application. <br />'fo� r and� vour �� <br />and addresswill � �� informationwhen <br />receivedbytheBoard. �lltheotherinformation <br />thatyou provide will be private data aboutyou <br />untiltheBoardissuesyourpermit. Whenthe <br />Board issuesyourpermit, ai I of the information <br />thatyou have provided to the Board in the <br />process of applyin gfor your permitwi I I become <br />public. If the Board does not issue you a <br />permit, allthe informationyou have provided <br />inthe processof applyingfora permitremains <br />private, with the exception ofyour name and <br />your organization's name and addresswhich <br />will remain public. <br />Private data about you are available only to <br />the following: �c members, staff of N1e <br />Boardwhoseworkassignment requiresth� <br />they have access to the information; the <br />Minnesota Departmentof Public Safeiy; the <br />MinnesotaAttorneyGeneral; the Minnesota <br />CommissionersofAdministration, Finance, <br />and Revenue; the Minnesota Legislative <br />Auditor, nationalandinternationalgambling <br />regulatory agendes; anyone pursuantto court <br />order; otherindividualsandagenciesthatare <br />specifically authorized by state or federal law <br />to have accessto the information; individuals <br />and agencies for which law or legal order <br />authorizesa newuseorsharingofinformation <br />afterthis Notice was given; and anyonewith <br />yourconsent. <br />